The impact of executive function on response to cognitive behavioral therapy in late-life depression

Reward and Punishment Learning as Predictors of Cognitive Behavioral Therapy Response in Parkinson's Disease Comorbid with Clinical Depression

Depression is highly comorbid among individuals with Parkinson's Disease (PD), who often experience unique challenges to accessing and benefitting from empirically supported interventions like Cognitive Behavioral Therapy (CBT). Given the role of reward processing in both depression and PD, this study analyzed a subset (N = 25) of participants who participated in a pilot telemedicine intervention of PD-informed CBT, and also completed a Reward- and Punishment-Learning Task (RPLT) at baseline. At the conclusion of CBT, participants were categorized into treatment responders (n = 14) and non-responders (n = 11). Responders learned more optimally from negative rather than positive feedback on the RPLT, while this pattern was reversed in non-responders. Computational modeling suggested group differences in learning rate to negative feedback may drive the observed differences. Overall, the results suggest that a within-subject bias for punishment-based learning might help to predict response to CBT intervention for depression in those with PD.Plain Language Summary Performance on a Computerized Task may predict which Parkinson's Disease Patients benefit from Cognitive Behavioral Treatment of Clinical DepressionWhy was the study done? Clinical depression regularly arises in individuals with Parkinson's Disease (PD) due to the neurobiological changes with the onset and progression of the disease as well as the unique psychosocial difficulties associated with living with a chronic condition. Nonetheless, psychiatric disorders among individuals with PD are often underdiagnosed and likewise undertreated for a variety of reasons. The results of our study have implications about how to improve the accuracy and specificity of mental health treatment recommendations in the future to maximize benefits for individuals with PD, who often face additional barriers to accessing quality mental health treatment.What did the researchers do? We explored whether performance on a computerized task called the Reward- and Punishment-Learning Task (RPLT) helped to predict response to Cognitive Behavioral Therapy (CBT) for depression better than other predictors identified in previous studies. Twenty-five individuals with PD and clinical depression that completed a 10-week telehealth CBT program were assessed for: Demographics (Age, gender, etc.); Clinical information (PD duration, mental health diagnoses, levels of anxiety/depression, etc.); Neurocognitive performance (Memory, processing speed, impulse control, etc.); and RPLT performance.What did the researchers find? A total of 14 participants significantly benefitted from CBT treatment while 11 did not significantly benefit from treatment.There were no differences before treatment in the demographics, clinical information, and neurocognitive performance of those participants who ended up benefitting from the treatment versus those who did not.There were, however, differences before treatment in RPLT performance so that those individuals that benefitted from CBT seemed to learn better from negative feedback.What do the findings mean? Our results suggest that the CBT program benefitted those PD patients with clinical depression that seemed to overall learn best from avoiding punishment rather than obtaining reward which was targeted in CBT by focusing on increasing engagement in rewarding activities. The Reward- and Punishment-Learning Task hence may be a useful tool to help predict treatment response and provide more individualized recommendations on how to best maximize the benefits of psychotherapy for individuals with PD that may struggle to connect to mental health care. Caution is recommended about interpretating these results beyond this study as the overall number of participants was small and the data for this study were collected as part of a previous study so there was no opportunity to include additional measurements of interest.

Who are you after psychedelics? A systematic review and a meta-analysis of the magnitude of long-term effects of serotonergic psychedelics on cognition/creativity, emotional processing and personality

This systematic review and a meta-analysis synthesised the results from contemporary, randomized and non-randomized controlled studies to assess lasting (one week minimum) changes on cognition/creativity, emotional processing and personality from serotonergic psychedelics. PubMed, Embase and PsycInfo were searched in July 2022. Risk of bias was assessed using Rob 2.0 and ROBINS-I. Ten studies met the eligibility criteria which involved 304 participants. No statistically significant effects were found for the majority outcome measures across the three constructs. A meta-analysis of emotional recognition outcomes found an overall significant effect for faster reaction times in the active treatment groups for disgust (SMD=-0.63, 95% CI=[-1.01 to -0.25], I2 = 65%) and sadness (SMD=-0.45, 95% CI=[-0.85 to -0.06], I2 = 60%). Future research should include larger samples, better control conditions, standardized doses and longer follow-up periods to confirm these preliminary findings.

Chronic exercise interventions for executive function in overweight children: a systematic review and meta-analysis

Objectives

To systematically evaluate the effectiveness of chronic exercise in physical activity (PA) as an intervention for executive functions (EFs) in children.

Methods

We conducted a systematic search in the following online databases: Web of Science, Cochrane Library, PubMed, Embase, and EBSCOhost. The timing is from database inception to July 2023, following PRISMA guidelines. Our inclusion criteria required studies reporting executive function (EF) levels in overweight children (age 0-18 years) before and after interventions. The Cochrane risk of bias tool assessed study bias, and Egger's test examined publication bias. Subgroup analyses considered three moderators: intervention duration, weekly frequency, and session length.

Results

The meta-analysis included a total of 10 studies with 843 participants. It revealed a statistically significant yet relatively small overall positive effect (g = 0.3, 95% CI 0.16-0.44, P < 0.01) of chronic exercise on EF in overweight children. Importantly, there was no significant heterogeneity (Q = 11.64, df = 12, P = 0.48; I2 = 0).

Conclusions

Chronic exercise interventions had a consistent positive impact on EF, irrespective of intervention duration, weekly frequency, or session length. However, given limitations in the number and design of studies, further high-quality research is needed to strengthen these conclusions.

Systematic Review Registration

PROSPERO identifier (CRD42023468588).

Performance-based attentional control, but not self-reported attentional control, predicts changes in depressive symptoms in short-term psychotherapy

OBJECTIVE

Although impairments in attentional control are pervasive across psychopathology, there is substantial individual differences. In the current study, we examined whether individual differences in self-reported and performance-based measures of attentional control predict changes in depressive symptoms and well-being in a diagnostically diverse sample of patients attending a CBT-based partial hospital program.

METHOD

Participants were 89 patients (56.2% men, 75.3% non-Hispanic White). At baseline, patients completed the self-reported Attentional Control Scale and the Rapid Serial Visual Presentation task (RSVP), a behavioral measure of attentional control. Depressive symptoms were assessed daily using the Patient Health Questionnaire and well-being was assessed using the Mental Health Continuum Short Form.

RESULTS

On average, greater self-reported attentional control was significantly associated with lower depressive symptoms, β = -0.49, t(52) = 4.84, p < .001, 95% CIs [-0.69, -0.29], and greater well-being, β = 0.45, t(53) = 3.90, p < .001, 95% CIs [0.22, 0.67]. More accurate task-based performance was associated with a decline in depressive symptoms over time, β = -0.02, t(32) = 2.50, p = .02, 95% CIs [-0.04, -0.01]. Neither self-reported nor performance-based measures of attentional control predicted changes in well-being. Finally, exploratory analyses suggest that depressive symptoms also improved over time for individuals who underestimated self-reported attentional control abilities relative to task-based performance, β = -0.19, t(32) = 2.23, p = .03, 95% CIs [-0.36, -0.02].

CONCLUSIONS

Results suggest that performance-based attentional control may be an important target for assessment and intervention, as well as a potential mechanism underlying risk and recovery.

Predictors and moderators of treatment outcome in late-life anxiety: A systematic review

BACKGROUND

The aim of this review was to identify and critically appraise predictors and moderators of outcomes of psychological and pharmacological treatments for late-life anxiety disorders. Their identification may guide the development of personalised treatments for older people with anxiety disorders.

METHODS

Web of Science, PsychINFO, CINAHL, Embase, and Pubmed were searched for studies published up to 12 May 2022. Randomised controlled trials and observational studies reporting treatment predictors and moderators were included. Participants with a diagnosis of any anxiety disorder who were aged over 60 years were included. Treatment outcomes included response, remission, and change in anxiety score.

RESULTS

Thirteen studies met the inclusion criteria. Twenty-three out of 49 predictors or moderators assessed at post-treatment, and 14 out of 33 predictors or moderators assessed at follow-up were statistically significant. Only one predictor, baseline worry severity at post-treatment, was reported in at least three studies. Most studies were rated as having a low risk of bias in at least three areas and satisfied important quality criteria for predictor and moderator analyses.

LIMITATIONS

Samples were predominantly white, female and highly educated, and most studies were secondary analyses.

CONCLUSIONS

There is evidence that baseline worry severity appears to predict treatment outcome in late-life anxiety disorders. However, this was only explored in psychological intervention studies and therefore its predictive ability in pharmacotherapy remains unknown. Future research should explore predictors and moderators in a range of anxiety disorders and design methodologically-strong and adequately-powered studies with the primary aim of assessing predictors of treatment outcomes.

Neurocognitive markers of passive suicidal ideation in late-life depression

OBJECTIVES

(1) To delineate whether cognitive flexibility and inhibitory ability are neurocognitive markers of passive suicidal ideation (PSI), an early stage of suicide risk in depression and (2) to determine whether PSI is associated with volumetric differences in regions of the prefrontal cortex (PFC) in middle-aged and older adults with depression.

DESIGN

Cross-sectional study.

SETTING

University medical school.

PARTICIPANTS

Forty community-dwelling middle-aged and older adults with depression from a larger study of depression and anxiety (NIMH R01 MH091342-05 PI: O'Hara).

MEASUREMENTS

Psychiatric measures were assessed for the presence of a DSM-5 depressive disorder and PSI. A neurocognitive battery assessed cognitive flexibility, inhibitory ability, as well as other neurocognitive domains.

RESULTS

The PSI group (n = 18) performed significantly worse on cognitive flexibility and inhibitory ability, but not on other neurocognitive tasks, compared to the group without PSI (n = 22). The group with PSI had larger left mid-frontal gyri (MFG) than the no-PSI group. There was no association between cognitive flexibility/inhibitory ability and left MFG volume.

CONCLUSIONS

Findings implicate a neurocognitive signature of PSI: poorer cognitive flexibility and poor inhibitory ability not better accounted for by other domains of cognitive dysfunction and not associated with volumetric differences in the left MFG. This suggests that there are two specific but independent risk factors of PSI in middle- and older-aged adults.

Neuroscience-based psychotherapy: A position paper

In the recent years, discoveries in neuroscience have greatly impacted upon the need to modify therapeutic practice starting from the evidence showing some cerebral mechanisms capable of coping with mental health crisis and traumatic events of the individual's life history by redesigning the narrative plot and the person's sense of the Self. The emerging dialogue between neuroscience and psychotherapy is increasingly intense and modern psychotherapy cannot ignore the heritage deriving from studies about neuropsychological modification of memory traces, neurobiology of attachment theory, cognitive mechanisms involved in psychopathology, neurophysiology of human empathy, neuroimaging evidence about psychotherapeutic treatment, and somatoform disorders connecting the brain and the body. In the present article, we critically examined sectorial literature and claimed that psychotherapy has to referred to a neuroscience-based approach in order to adopt the most tailored interventions for specific groups of patients or therapy settings. We also provided recommendations for care implementation in clinical practice and illustrated challenges of future research.

The Role of Emotion Regulation and Executive Functioning in the Intervention Outcome of Children with Emotional and Behavioural Problems

Emotional and behavioural problems are closely associated with impairments in regulating emotions and in executive functions (EF). To examine this further, the aim of the present study was to determine whether EF and emotion regulation at baseline would predict emotional and behavioural problem scores post-intervention, and further explore the extent to which emotion regulation mediates these outcomes. Participants were 41 primary school children who exhibited emotional and/or behavioural problems, aged 8 to 11 years. All the children completed measures of emotional and behavioural problems, cognitive emotion regulation, anxiety symptoms, and performed two experimental tasks to measure working memory and response inhibition before and after participating in a transdiagnostic Cognitive Behaviour Therapy-based programme, "Super Skills for Life" (SSL), and at 3-months follow-up. Results revealed significant reduction in the use of maladaptive emotion regulation strategy catastrophising and other blame following the intervention. Additionally, EF and emotion regulation was associated with outcomes for emotional problems and conduct problems. More specifically maladaptive emotion regulation strategy such as catastrophising and other blame was closely related with self-reports of emotional problems, likewise other blame, was also linked with scores of conduct problems. This study provides preliminary empirical support for EF and emotion regulation in predicting outcomes of emotional and behavioural problems in children following intervention.

Executive Functions of Adults with Binge-Eating Disorder: The Role of Weight Status and Psychopathology

Findings on executive functions (EFs) in binge-eating disorder (BED) are inconsistent and possibly biased by associated comorbidities. This study aimed to identify whether distinct levels of physical and mental comorbidity are related to EFs in BED. General and food-specific EFs in n = 77 adults with BED were compared to population-based norms and associations with weight status, depressive symptoms, and eating disorder psychopathology were analyzed. To detect within-sample patterns of EF performance, k-means clustering was applied. The results indicated that participants' general EFs were within the average range with slight deficits in alertness. While depression and eating disorder psychopathology were unrelated to EFs, weight status was associated with food-specific attentional bias that was significantly higher in obesity class 2 than in overweight/obesity class 1 and obesity class 3. Four meaningful clusters with distinct strengths and impairments in general and food-specific EFs but without differences in clinical variables were identified. Altogether, adults with BED showed few specific deficits compared to normative data. Performance was unrelated to depression and eating disorder psychopathology, while weight status was associated with food-specific EFs only. The results highlight the need for longitudinal studies to evaluate the relevance of EFs in BED development and maintenance in neurologically healthy adults.

Lifetime trauma history and cognitive functioning in major depression and their role for cognitive-behavioral therapy outcome

Background

While cognitive-behavioral therapy (CBT) is the gold-standard psychological treatment for major depression (MD), non-response and lacking stability of treatment gains are persistent issues. Potential factors influencing treatment outcome might be lifetime trauma history and possibly associated primarily prefrontal-cortex- and hippocampus-dependent cognitive alterations.

Method

We investigated MD and healthy control participants with (MD+T+, n = 37; MD-T+, n = 39) and without lifetime trauma history (MD+T-, n = 26; MD-T-, n = 45) regarding working memory, interference susceptibility, conflict adaptation, and autobiographical memory specificity. Further, MD+T+ (n = 21) and MD+T- groups (n = 16) were re-examined after 25 CBT sessions, with MD-T- individuals (n = 34) invited in parallel in order to explore the stability of cognitive alterations and the predictive value of lifetime trauma history, cognitive functioning, and their interaction for treatment outcome.

Results

On a cross-sectional level, MD+T+ showed the highest conflict adaptation, but MD+T- the lowest autobiographical memory specificity, while no group differences emerged for working memory and interference susceptibility. Clinical improvement did not differ between groups and cognitive functioning remained stable over CBT. Further, only a singular predictive association of forward digit span, but no other facets of baseline cognitive functioning, lifetime trauma history, or their interaction with treatment outcome emerged.

Discussion

These results indicate differential roles of lifetime trauma history and psychopathology for cognitive functioning in MD, and add to the emerging literature on considering cognitive, next to clinical remission as a relevant treatment outcome.

Longitudinal Changes of Cognitive Deficits and Treatment Outcome of Cognitive Behavioral Therapy for Major Depression

ABSTRACT

The current study examined neuropsychological changes over the course of cognitive behavioral therapy (CBT) in outpatients with major depressive disorder and the influence of cognitive deficits as predictors of clinical outcome in depression. A neuropsychological test battery was carried out on depressed outpatients (N = 54) at the beginning and at the end of CBT. Small improvements were found in divided attention, figural memory, and processing speed from pre- to posttreatment. Cognitive deficits in executive functions before treatment predicted the clinical outcome at the end of CBT. The present study reveals that attention and memory deficits are most likely to improve over the course of treatment, whereas executive functions remain stable in the long term. Depressed patients with worse executive functions at the beginning of treatment seem to benefit more from long-term CBT therapy.

[Mental disorders after acquired CNS damage]

Mental disorders are a frequent consequence of acquired central nervous damage. If not recognized and treated early, they have a negative impact on the course of neurological rehabilitation. This article deals with the diagnosis and treatment of mental disorders after acquired damage to the central nervous system.

Comparing objective cognitive impairments in patients with peripheral neuropathic pain or fibromyalgia

Existing studies on cognitive impairments in chronic pain do not investigate peripheral neuropathic pain (PNP) or compare pain conditions in a satisfactory manner. Here we aimed to compare executive dysfunctions in PNP patients with fibromyalgia (FM) and healthy controls (HC). Patients who self-reported cognitive impairments were assessed according to criteria for PNP or FM. Seventy-three patients met criteria and completed testing on executive functioning and IQ measures. We also included twenty matched healthy controls. Regression models controlling for age, sex and IQ, tested associations between group category (PNP, FM or HC) and outcomes. If a substantial association was detected, we followed up with head-to-head comparisons between PNP and FM. Multivariate regression models then tested associations between executive functioning and pain type, controlling for significant confounders. Results from head-to-head comparison between pain conditions showed significant differences on years lived with pain (FM > PNP), the use of anticonvulsants (PNP > FM) and use of analgesics (PNP > FM). When controlled for all significant differences, PNP patients had significantly lower scores on an attention-demanding cued-recall task compared to FM. Poor performance on attention-demanding cued-recall task was associated with PNP, which translate into problems with retaining fast-pace or advanced information.

Neurocognitive predictors of treatment completion and daytime activities at follow-up in multiproblem young adults

Previous research has shown an association between cognitive control deficits and problematic behavior such as antisocial behavior and substance use, but little is known about the predictive value of cognitive control for treatment outcome. The current study tests whether selected markers of baseline cognitive control predict (1) treatment completion of a day treatment program involving a combination of approaches for multiproblem young adults and (2) daytime activities a year after the start of treatment, over and above psychological, social, and criminal characteristics. We assessed individual, neurobiological, and neurobehavioral measures, including functional brain activity during an inhibition task and two electroencephalographic measures of error processing in 127 male multiproblem young adults (age 18-27 years). We performed two hierarchical regression models to test the predictive power of cognitive control for treatment completion and daytime activities at follow-up. The overall models did not significantly predict treatment completion or daytime activities at follow-up. However, activity in the anterior cingulate cortex (ACC) during response inhibition, years of regular alcohol use, internalizing problems, and ethnicity were all significant individual predictors of daytime activity at follow-up. In conclusion, cognitive control could not predict treatment completion or daytime activities a year after the start of treatment over and above individual characteristics. However, results indicate a direct association between brain activity during response inhibition and participation in daytime activities, such as work or school, after treatment. As adequate baseline inhibitory control is associated with a positive outcome at follow-up, this suggests interventions targeting cognitive control might result in better outcomes at follow-up.

The effects of retrieval versus rehearsal of online problem-solving therapy sessions on recall, problem-solving skills and distress in distressed individuals: An experimental study

BACKGROUND AND OBJECTIVES

Improving memory for the content of therapy sessions might increase the effects of psychological interventions. Previous studies showed that healthy individuals who took a memory test (retrieval) of studied material showed better long-term memory retention than individuals who restudied (rehearsal) the material. The aim of the current study was to find out whether we can translate these findings to a subclinical setting.

METHODS

Individuals with moderate levels of distress were randomized into retrieving (n = 46) or rehearsing (n = 49) four weekly sessions of online Problem-Solving Therapy (PST). Session recall, problem-solving skills and distress were measured at baseline, three days after each session and at one-week follow-up.

RESULTS

Retrieval led to overall higher recall, but this difference disappeared when controlling for the time spent on retrieval versus rehearsal. Retrieval did not lead to better problem-solving skills or less distress, compared to rehearsal. Baseline working memory performance moderated the effect of condition on recall after controlling for the time spent on retrieval versus rehearsal: the effect of retrieval compared to rehearsal on recall was larger for individuals with lower working memory performance.

LIMITATIONS

The sample mostly consisted of university students with overall high working memory scores.

CONCLUSIONS

This study provided the first evidence that retrieval of the content of PST sessions may lead to better session recall compared to rehearsal of the PST sessions in individuals with a low working memory score. Implications for the use of cognitive support strategies within a therapeutic setting are discussed.

Cross-sectional and prospective inter-relationships between depressive symptoms, vascular disease and cognition in older adults

BACKGROUND

It has been proposed that vascular disease is the mechanism linking depression and cognition, but prospective studies have not supported this hypothesis. This study aims to investigate the inter-relationships between depressive symptoms, cognition and cerebrovascular disease using a well-characterised prospective cohort.

METHOD

Data came from waves 1 (2005-2007) and 2 (2007-2009) of the Sydney Memory and Ageing Study (n = 462; mean age = 78.3 years).

RESULTS

At wave 1, there was an association between depressive symptoms and white matter hyperintensity (WMH) volume [b = 0.016, t(414) = 2.34, p = 0.020]. Both depressive symptoms [b = -0.058, t(413) = -2.64, p = 0.009] and WMH volume [b = -0.011, t(413) = -3.77, p < 0.001], but not stroke/transient ischaemic attack (TIA) [b = -0.328, t(413) = -1.90, p = 0.058], were independently associated with lower cognition. Prospectively, cerebrovascular disease was not found to predict increasing depressive symptoms [stroke/TIA: b = -0.349, t(374.7) = -0.76, p = 0.448; WMH volume: b = 0.007, t(376.3) = 0.875, p = 0.382]. Depressive symptoms predicted increasing WMH severity [b = 0.012, t(265.9) = -3.291, p = 0.001], but not incident stroke/TIA (odds ratio = 0.995; CI 0.949-1.043; p = 0.820). When examined in separate models, depressive symptoms [b = -0.027, t(373.5) = -2.16, p = 0.032] and a history of stroke/TIA [b = -0.460, t(361.2) = -4.45, p < 0.001], but not WMH volume [b = 0.001, t(362.3) = -0.520, p = 0.603], predicted declines in cognition. When investigated in a combined model, a history of stroke/TIA remained a predictor of cognitive decline [b = -0.443, t(360.6) = -4.28, p < 0.001], whilst depressive symptoms did not [b = -0.012, t(359.7) = -0.96, p = 0.336].

CONCLUSIONS

This study is contrasted with previous prospective studies which indicate that depressive symptoms predict cognitive decline independently of vascular disease. Future research should focus on further exploring the vascular mechanisms underpinning the relationship between depressive symptoms and cognition.

Neuropsychological Functioning in Older Adults with Mild Cognitive Impairment and Insomnia Randomized to CBT-I or Control Group

OBJECTIVES

Improving the sleep of older adults with mild cognitive impairment (MCI) represents a first step in discovering whether interventions directed at modifying this risk factor also have the potential to alter the cognitive decline trajectory.

METHODS

A six-session, adapted version of a cognitive behavioral therapy for insomnia (CBT-I) was administered to older adults (N = 28; 14 per group) with MCI across two residential facilities. Participants were randomly assigned to either the sleep intervention or an active control group and completed a neuropsychological battery at three time points (e.g., baseline-T1, post-intervention-T2, 4 month follow-up-T3).

RESULTS

Results showed a significant improvement in sleep and a change (p < .05) on a key measure of executive functioning sub task of inhibition (Condition 3 of D-KEF Color-Word Interference Test), a positive trend on the inhibition-switching task (p < .10; Condition 4 of D-KEF Color-Word Interference Test), an no change in a measure of verbal memory (HVLT-R Delayed Recall) compared with the active control group.

CONCLUSIONS

CBT-I is a nonpharmacological intervention that has the potential to cognitively benefit individuals with MCI suffering from comorbid insomnia.

CLINICAL IMPLICATIONS

Results suggest that a non-pharmacological intervention to improve sleep in older adults with MCI also improve cognitive functioning. Further exploration of the mechanisms underlying these improvements is warranted.

Predictors of treatment outcome in depression in later life: A systematic review and meta-analysis

BACKGROUND

Predictor analyses of late-life depression can be used to identify variables associated with outcomes of treatments, and hence ways of tailoring specific treatments to patients. The aim of this review was to systematically identify, review and meta-analyse predictors of outcomes of any type of treatment for late-life depression.

METHODS

Pubmed, Embase, CINAHL, Web of Science and PsycINFO were searched for studies published up to December 2016. Primary and secondary studies reported treatment predictors from randomised controlled trials of any treatment for patients with major depressive disorder aged over 60 were included. Treatment outcomes included response, remission and change in depression score.

RESULTS

Sixty-seven studies met the inclusion criteria. Of 65 identified statistically significant predictors, only 7 were reported in at least 3 studies. Of these, 5 were included in meta-analyses, and only 3 were statistically significant. Most studies were rated as being of moderate to strong quality and satisfied key quality criteria for predictor analyses.

LIMITATIONS

The searches were limited to randomised controlled trials and most of the included studies were secondary analyses.

CONCLUSIONS

Baseline depression severity, co-morbid anxiety, executive dysfunction, current episode duration, early improvement, physical illnesses and age were reported as statistically significant predictors of treatment outcomes. Only the first three were significant in meta-analyses. Subgroup analyses showed differences in predictor effect between biological and psychosocial treatment. However, high heterogeneity and small study numbers suggest a cautious interpretation of results. These predictors were associated with various mechanisms including brain pathophysiology, perceived social support and proposed distinct types of depressive disorder. Further investigation of the clinical utility of these predictors is suggested.

Therapeutic relationship in the treatment of geriatric depression with executive dysfunction

BACKGROUND

The effects of therapeutic relationship (TR) in elder mental health are understudied. A greater understanding of TR in geriatric psychotherapy is particularly needed for treating late-life depression with executive dysfunction, which predicts poor response to antidepressant medication and presents unique clinical challenges.

METHODS

Participants were older patients (N = 220) with major depression and executive dysfunction who received 12 weeks of problem-solving therapy or supportive therapy in a randomized control trial. Multilevel growth curve modeling and latent change scores were used to analyze TR dimensions of Understanding and Accepting at the patient level (individual patient ratings, N = 194) and therapist level (ratings of each therapist averaged across participants, N = 10).

RESULTS

TR predicted reduction of depression in both treatment groups, while treatment×TR interactions were not significant. Patients treated by therapists with higher average Understanding (patient and therapist level) and Accepting (therapist level) ratings had greater decreases in depression. The patient level×therapist level interaction for Understanding approached statistical significance (p=.065), suggesting a synergistic effect on treatment outcome. Together, Understanding and Accepting predicted 21% of variance in depression level changes.

LIMITATIONS

TR was not assessed throughout the course of treatment (only after the first therapy session and at post-treatment) and did not include ratings from an objective evaluator.

CONCLUSIONS

Assessment of patient's experience of the TR and of therapist ability to foster Understanding and Accepting can play a significant role in the delivery of geriatric psychosocial interventions.

Handling clinical comorbidity in randomized clinical trials in psychiatry

The purpose of this paper is to a) outline the importance of including patients with clinical comorbidities in Randomized Clinical Trials (RCTs) of psychiatric treatments; and b) to propose a specific approach for best handling, analyzing and interpreting the data on clinical comorbidities in terms of their impact on treatment outcomes. To do this we first define and describe clinical comorbidity and differentiate it from other forms of comorbidity. We then describe the methodological and analytical problems associated with excluding patients with clinically comorbid conditions from RCTs, including the impact on the outcomes of RCTs in psychiatry and the impact on evidence-based clinical decision-making. We then address the challenges inherent to including patients with clinical comorbidities in RCTs. Finally, we propose a methodological and analytic approach to deal with these issues in RCTs which aims to significantly improve the information yielded from RCTs in psychiatry, and thus improve clinical decision-making.

Psychosocial Treatment Options for Major Depressive Disorder in Older Adults

Late-life depression (LLD) is a public health concern with deleterious effects on overall health, cognition, quality of life, and mortality. Although LLD is relatively common, it is not a normal part of aging and is often under-recognized in older adults. However, psychotherapy is an effective treatment for LLD that aligns with many patients' preferences and can improve health and functioning. This review synthesized the current literature on evidence-based psychotherapies for the treatment of depression in older adults. Findings suggest that active, skills-based psychotherapies (cognitive behavioral therapy [CBT] and problem-solving therapy [PST]) may be more effective for LLD than non-directive, supportive counseling. PST may be particularly relevant for offsetting skill deficit associated with LLD, such as in instances of cognitive impairment (especially executive dysfunction) and disability. Emerging treatments also consider contextual factors to improve treatment delivery, such as personalized care, access, and poverty. Tele-mental health represents one such exciting new way of improving access and uptake of treatment by older adults. Although these strategies hold promise, further investigation via randomized controlled trials and comparative effectiveness are necessary to advance our treatment of LLD. Priority should be given to recruiting and training the geriatric mental health workforce to deliver evidence-based psychosocial interventions for LLD.

Cognitive Behavioral Therapy for Anxiety in Cognitively Intact Older Adults

This article discusses potential adaptations to cognitive behavioral therapy (CBT) needed when working with older adults. Although CBT has been demonstrated to be efficacious in older anxious populations in meta-analyses, more research is needed to better understand the efficacy of CBT for the individual anxiety disorders, for older adults aged 80 years and older, and the efficacy of individual CBT elements. Despite normal age-related reductions in cognitive and physical abilities, most research suggests that only minor adaptations to CBT, if any, are needed for older adults. More significant adaptations relate to therapist attitudes and beliefs rather than the pragmatic CBT delivery, for example, negative attitudes related to aging and the likely benefit of CBT. Despite normal age-related declines in some cognitive domains, research to date suggests that normal cognitive changes do not significantly impact on treatment outcomes over the course of CBT; a case example is presented.

Neurocognitive Correlates of Successful Treatment of PTSD in Female Veterans

BACKGROUND

The influence of psychotherapy on neurocognition in post-traumatic stress disorder (PTSD) has not been examined methodically. This is despite evidence that pre-treatment learning and memory has been associated with treatment success and that executive function theories emphasize weak executive functions (especially inhibition/switching) are associated with PTSD.

OBJECTIVES

To determine (1) if higher pre-treatment learning/memory, inhibition/switching, or both predict treatment success; and (2) if treatment success is associated with specific improvement in inhibition/switching and not learning/memory or working memory, another aspect of executive function.

METHODS

Pre-treatment neurocognition and neurocognitive changes (inhibition/switching, learning/memory, working memory) were examined in female veterans with PTSD. They were evaluated before and after 16-weeks of group psychotherapy for PTSD that included three counterbalanced modules (cognitive restructuring therapy, exposure therapy, skills training) with fidelity checks for therapist adherence.

RESULTS

Only pre-treatment learning/memory predicted better treatment outcome. Treatment success was associated with improvement in inhibition/switching only, even after controlling for mild traumatic brain injury, and changes in depressive symptoms, working memory, and learning/memory.

CONCLUSIONS

Our finding that learning/memory predicted treatment success is consistent with previous studies. We extended these studies by showing that the effect was restricted to learning/memory, which is contrary to the executive function theory of PTSD. In contrast, the fact that only inhibition/switching significantly improved with better treatment success is consistent with its potential importance in maintaining PTSD symptoms. Future research should determine whether inhibition/switching abilities are a risk for development and maintenance of PTSD or whether such abilities have a broader reciprocal relationship with PTSD symptom change. (JINS, 2016, 22, 643-651).